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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-602 – September 21, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. Segal, Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On Tuesday, December 17, 1991, the Employee’s spouse sought evaluation and treatment at a local hospital emergency room complaining of a sore throat, cough and a shortness of breath. The emergency room record indicates that the Employee’s spouse was examined by the emergency room physician and was diagnosed as having an upper respiratory infection. She was given a prescription for an antibiotic and a cough syrup. The Employer provided benefits for the emergency room physician, but denied the $45.00 charge for the emergency room as the patient’s condition did not warrant emergency treatment. The Employer states that the care provided was not for the treatment of acute medical symptoms, and therefore, ineligible under the terms of the Employer Benefit Plan.
Dispute
Is the Employer required to provide benefits for the emergency room charge incurred by the Employee’s spouse on December 17, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room Employee’s spouse’s use of the emergency room on December 17, 1991 because the spouse’s symptoms were acute and required immediate attention.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s spouse on December 17, 1991 because the spouse’s condition was not a medical emergency and did not require emergency treatment.
Pertinent Provisions
Article III. A. (2) (a) of the Employer Benefit Plan states:
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provided for a Beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
Discussion
Article III. A. (2) (a) of the Employer Benefit Plan provides that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the emergency room record of December 17, 1991 and has advised that the patient’s history and physical examination did not reveal any justification for an emergency room visit. The consultant noted that the visit had taken place on a Tuesday at 12:01 p.m., and that at this time of day treatment could have been sought at an outpatient clinic or physician’s office. The consultant further states that the patient’s temperature was only slightly elevated and all other vital signs were normal. For these reasons, it is the consultant’s opinion that the visit in question does not meet the requirements of emergency medical care as defined by Article III. A. (2) (a) of the Employer Benefit Plan.
It is, therefore, the opinion of the Trustees that the Employee’s spouse’s emergency room visit would not be eligible for benefits under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s spouse on December 17, 1991.